MEDICARE: DR. DIANA JOLYNN CARLSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	5101017651	MI

General Provider Information

NPI Number	:	1689825564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANA JOLYNN CARLSON D.O.

Provider Business Mailing Address
First Line	:	100 N POND DR
Second Line	:	SUITE C
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3079
Country	:	US
Telephone Number	:	248-624-2222
Fax Number	:	248-926-9455

Provider Business Practice Location Address
First Line	:	100 N POND DR
Second Line	:	SUITE C
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3079
Country	:	US
Telephone Number	:	248-624-2222
Fax Number	:	248-926-9455

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2008
Last Update Date	:	04/14/2014

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